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Schoel LJ, Sinamo J, Williams J, Hallway A, Fry BT, Rubyan M, Shao JM, O'Neill SM, Telem DA, Ehlers AP. Heterogeneity in the surgical approach to recurrent abdominal wall hernias: an opportunity for quality improvement. Surg Endosc 2024:10.1007/s00464-024-11256-1. [PMID: 39299962 DOI: 10.1007/s00464-024-11256-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 08/31/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Despite being a challenging and morbid clinical problem, operative approaches to recurrent abdominal wall hernia repairs receive little attention. Given this, we performed a retrospective study to evaluate surgical techniques of recurrent abdominal wall hernias requiring reoperation. METHODS Adult patients from the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC-COHR) were included in this study. All elective ventral hernia operations performed between January 1, 2020, and March 31, 2023, were included. Descriptive analyses via t-tests and Fisher exact tests were conducted to evaluate sociodemographic, operative, and hernia-specific attributes associated with primary and recurrent hernia repairs. RESULTS We identified 8587 patients who underwent elective abdominal wall hernia repair. Of these, 7887 (91.8%) underwent primary repair, and 700 (8.2%) underwent recurrent repair. Patients who underwent recurrent hernia repair were older (mean age 57.9 years vs. 54.1 years, p < 0.001), more often female (53.8% vs. 41.9%, p < 0.001), and had higher BMI (34.0 vs. 32.6, p < 0.001). Patients with recurrent hernias were more likely to have comorbid conditions including hypertension (p < 0.001), diabetes (p < 0.005), COPD (p < 0.01), and BMI > 40 (p < 0.05). Recurrent hernia repairs were more likely to have any 30-day complication (6.4% versus 1.9%, p < 0.001), including higher rates of all surgical site infections. There was no difference in 30-day readmission rates. CONCLUSION Considerable variation persists in operative management of recurrent abdominal wall hernias. Importantly, not all recurrent hernias were managed with mesh, which may precipitate additional recurrences and further morbidity. Understanding outcomes for these varied approaches to recurrent hernia repairs is critical to optimize management of this complex clinical problem and prevent future episodes of recurrence.
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Affiliation(s)
- Leah J Schoel
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Center for Healthcare Outcomes and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Joshua Sinamo
- Center for Healthcare Outcomes and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jonathan Williams
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Alexander Hallway
- Center for Healthcare Outcomes and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Brian T Fry
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Michael Rubyan
- Center for Healthcare Outcomes and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Epidemiology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Health Management and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jenny M Shao
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Sean M O'Neill
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Dana A Telem
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Anne P Ehlers
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
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Naga HI, Oyola AM, Kim JK, Hope WW, Farber L, Yoo JS. Retrorectus Ventral Hernia Repair Utilizing T-line Hernia Mesh: Technical Descriptions. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6101. [PMID: 39188965 PMCID: PMC11346900 DOI: 10.1097/gox.0000000000006101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 07/01/2024] [Indexed: 08/28/2024]
Abstract
The T-line hernia mesh is a synthetic, polypropylene mesh with mesh suture extensions designed to prevent anchor point failure by evenly distributing tension across the soft tissue. Previous studies have demonstrated the success of onlay ventral hernia repair with T-line hernia mesh, but retrorectus applications of the mesh have not yet been characterized. This technique article illustrates technical descriptions and clinical applications of the T-line hernia mesh in the retrorectus plane.
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Affiliation(s)
- Hani I. Naga
- From the Department of Surgery, Duke University Medical Center, Durham N.C
| | - Anna Malysz Oyola
- Department of General Surgery, Novant Health New Hanover Regional Medical Center, Wilmington, N.C
| | - Joshua K. Kim
- From the Department of Surgery, Duke University Medical Center, Durham N.C
| | - William W. Hope
- Department of General Surgery, Novant Health New Hanover Regional Medical Center, Wilmington, N.C
| | | | - Jin S. Yoo
- From the Department of Surgery, Duke University Medical Center, Durham N.C
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Dias Rasador AC, da Silveira CAB, Lima DL, Nogueira R, Malcher F, Sreeramoju P, Cavazzola LT. Mesh versus suture for elective primary umbilical hernia open repair: a systematic review and meta-analysis. Hernia 2024:10.1007/s10029-024-03106-9. [PMID: 39001938 DOI: 10.1007/s10029-024-03106-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 07/01/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR. METHODS We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%. RESULTS 2895 studies were screened and 56 were reviewed. 12 studies, including 4 RCTs, 1 prospective cohort, and 7 retrospective cohorts were included, comprising 2926 patients in total (47.6% in mesh group and 52.4% in the suture group). Mesh repair showed lower rates of recurrence in the overall analysis (RR 0.50; 95% CI 0.31 to 0.79; P = 0.003; I2 = 24%) and for hernia defects smaller than 2 cm (RR 0.56; 95% CI 0.34 to 0.93; P = 0.03; I2 = 0%). Suture repair showed lower rates of seroma (RR 1.88; 95% CI 1.07 to 3.32; P = 0.03; I2 = 0%) and wound infection (RR 1.65; 95%CI 1.12 to 2.43; P = 0.01; I2 = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay. CONCLUSION The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs. STUDY REGISTRATION A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).
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Affiliation(s)
- Ana Caroline Dias Rasador
- Bahiana School of Medicine and Public Health, Dom João VI Avenue, 275, Brotas, BA, 40290-000, Brazil
| | | | - Diego Laurentino Lima
- Department of Surgery, Montefiore Medical Center, 1825 Eastchester Rd, Bronx, NY, 10461, USA.
| | - Raquel Nogueira
- Department of Surgery, Montefiore Medical Center, 1825 Eastchester Rd, Bronx, NY, 10461, USA
| | - Flavio Malcher
- Division of General Surgery, NYU Langone, New York, NY, USA
| | - Prashanth Sreeramoju
- Bahiana School of Medicine and Public Health, Dom João VI Avenue, 275, Brotas, BA, 40290-000, Brazil
| | - Leandro T Cavazzola
- Department of Surgery, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Hernandez A, Petersen R. Laparoscopic Ventral Hernia Repair. Surg Clin North Am 2023; 103:947-960. [PMID: 37709398 DOI: 10.1016/j.suc.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
The laparoscopic approach to ventral hernia repair is a safe and effective approach for both elective and emergent repair. The preoperative technical considerations include assessment of incarceration and potential for extensive adhesiolysis, size of defect, and atypical hernia locations. Preoperative considerations include weight loss and lifestyle modification. There are multiple methods of fascial defect closure and mesh fixation that the surgeon may consider via a laparoscopic approach, making it adaptable to varying clinical scenarios and anatomic challenges. Compared with open repair laparoscopic repair is associated with reduced surgical wound site infection, and compared with robotic repair outcomes are similar.
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Affiliation(s)
- Alexandra Hernandez
- Department of Surgery, Division of General Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356410, Seattle, WA 98195, USA
| | - Rebecca Petersen
- Department of Surgery, Division of General Surgery, University of Washington, 1959 Northeast Pacific Street, Box 356410, Seattle, WA 98195, USA.
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Frey S, Beauvais A, Soler M, Beck M, Dugué T, Pavis d'Escurac X, Dabrowski A, Jurczak F, Gillion JF. Suture versus open mesh repair for small umbilical hernia: Results of a propensity-matched cohort study. Surgery 2023; 174:593-601. [PMID: 37357098 DOI: 10.1016/j.surg.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 04/14/2023] [Accepted: 05/24/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The objective was to compare the outcomes of open mesh repair versus suture repair for small (≤1 cm in diameter) umbilical hernia. The primary endpoint was the 30-day outcomes including pain, and secondary endpoints were the 2-year outcomes including recurrences and patient-reported outcomes. METHODS This propensity-matched, multicenter study was carried out on data collected prospectively in the Hernia-Club database between 2011 and 2021. A total of 590 mesh repairs and 590 suture repairs were propensity score matched (age, sex, body mass index) at a ratio of 1:1. Postoperative pain was assessed using the Verbal Rating Scale-4 and 0‒10 Numerical Rating Scale-11. RESULTS Mesh insertion was intraperitoneal in 331 patients (56.1%), extraperitoneal in 249 (42.2%), and onlay in 10 (1.7%). The rate of 30-day complications and Numerical Rating Scale-11 pain scores on postoperative days 8 and 30 were similar between the groups, including surgical site occurrences (2.2 vs 1.4% after suture repair). At 1 month, postoperative discomfort (sensation of something different from before) was significantly (P < .0001) more frequent after mesh repair, whereas the rate of relevant (moderate or severe) pain (mesh repair: 1.1% vs suture repair: 2.6%) and the distribution of Numerical Rating Scale-11 scores did not differ between the groups. At the 2-year follow-up, mesh repair patients had fewer reoperated recurrences (0.2% vs 1.7%; P = .035) and no more pain or discomfort than suture repair patients. CONCLUSION Both techniques are effective and safe. Mesh repair is likely to reduce the rate of recurrences. Concerns about postoperative pain and infection might not prevent the use of mesh in smallest umbilical hernias.
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Affiliation(s)
- Samuel Frey
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Nantes, France.
| | | | - Marc Soler
- Service de chirurgie viscérale et digestive, Clinique Saint-Jean, Cagnes-sur-Mer, France
| | | | - Timothée Dugué
- Service de chirurgie viscérale et digestive, Clinique Saint Pierre, Perpignan, France
| | | | - André Dabrowski
- Service de chirurgie viscérale et digestive, Clinique de Saint-Omer, Blendecques, France
| | - Florent Jurczak
- Service de chirurgie digestive et viscérale, Clinique Mutualiste de l'Estuaire, Saint-Nazaire, France
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Omameuda T, Shiozawa M, Miyahara Y, Kitabayashi H, Koizumi M, Kondo S, Kawai S, Kodama M. A rare presentation of linea alba hernia involving fibrolipoma of the hepatic round ligament: a case report and literature review. Surg Case Rep 2023; 9:91. [PMID: 37247100 DOI: 10.1186/s40792-023-01676-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/21/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Linea alba hernias are relatively rare types of hernias. They manifest as small protrusions situated in the linea alba between the umbilicus and xiphoid cartilage. Usually, hernia contents comprise the pre-peritoneal fat, omentum, and gastrointestinal tract. However, very few cases of linea alba hernias involving the hepatic round ligament have been reported, to date. CASE PRESENTATION An 80-year-old woman presented with upper abdominal pain and a 1-week history of a mass in the upper midline. Abdominal computed tomography revealed adipose tissue protruding from the abdominal wall contiguous with the hepatic round ligament, suggesting a linea alba hernia. During surgery, the hernial sac content was found to be a mass, which was resected. A linea alba hernia defect measuring 20 mm was repaired using a mesh. Histopathological findings revealed that the mass included mature adipocyte proliferation with broad fibrous septa, which was diagnosed as fibrolipoma of the hepatic round ligament. CONCLUSIONS We report the first case of a linea alba hernia involving fibrolipoma of the hepatic round ligament worldwide and describe the clinical features, diagnosis, and surgical procedure with a literature review.
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Affiliation(s)
- Takahiko Omameuda
- Department of Surgery, Tochigi Medical Center Shimotsuga, Ohiramachi Kawazure 420-1, Tochigi, Tochigi, 329-4498, Japan.
| | - Mikio Shiozawa
- Department of Surgery, Tochigi Medical Center Shimotsuga, Ohiramachi Kawazure 420-1, Tochigi, Tochigi, 329-4498, Japan
| | - Yuzo Miyahara
- Department of Surgery, Tochigi Medical Center Shimotsuga, Ohiramachi Kawazure 420-1, Tochigi, Tochigi, 329-4498, Japan
| | - Hiroyuki Kitabayashi
- Department of Surgery, Tochigi Medical Center Shimotsuga, Ohiramachi Kawazure 420-1, Tochigi, Tochigi, 329-4498, Japan
| | - Masaru Koizumi
- Department of Surgery, Tochigi Medical Center Shimotsuga, Ohiramachi Kawazure 420-1, Tochigi, Tochigi, 329-4498, Japan
| | - Satoru Kondo
- Department of Surgery, Tochigi Medical Center Shimotsuga, Ohiramachi Kawazure 420-1, Tochigi, Tochigi, 329-4498, Japan
| | - Shigeo Kawai
- Department of Pathology, Tochigi Medical Center Shimotsuga, Ohiramachi Kawazure 420-1, Tochigi, Tochigi, 329-4498, Japan
| | - Masaaki Kodama
- Department of Surgery, Tochigi Medical Center Shimotsuga, Ohiramachi Kawazure 420-1, Tochigi, Tochigi, 329-4498, Japan
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Moradian S, Klosowiak JL, Boctor MJ, Issa T, Park S, Dumanian GA. Novel Approach for Umbilical Hernia Repair Using Mesh Strips. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4947. [PMID: 37113310 PMCID: PMC10129195 DOI: 10.1097/gox.0000000000004947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/24/2023] [Indexed: 04/29/2023]
Abstract
Umbilical hernia repair is a common surgical procedure without a universally accepted means of repair. We introduce a novel surgical technique for open primary umbilical hernia repair, using strips of polypropylene mesh as sutures to achieve a repair. Methods Two-centimeter-wide strips of macroporous polypropylene mesh were passed through the abdominal wall and tied as simple interrupted sutures to achieve umbilical hernia repair. A retrospective review of all elective umbilical hernia repairs performed by a single surgeon using the mesh strip technique between 2016 and 2021 was conducted, and patient-reported outcomes were assessed via a telephonic survey. Results Thirty-three patients underwent an elective, open mesh strip repair of a primary umbilical hernia and met criteria for inclusion in the study. Of these patients, 60% responded to a patient-reported outcomes telephone survey. Ninety percent of survey responders reported a pain score of 0 of 10. Additionally, 90% reported being unable to feel or palpate the knot, and 80% reported an improvement in quality of life. Mean follow-up at 3 years revealed one recurrence in the setting of ascites, yielding a recurrence rate of 3%. Conclusion Primary mesh strip repair of umbilical hernias combines the simplicity of suture repair with the advantageous force distribution properties of mesh, and constitutes a safe, efficient, and effective method of repair with a low recurrence rate at long-term follow-up that is comparable to planar mesh repair.
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Affiliation(s)
- Simon Moradian
- From the Department of Surgery, Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Julian L. Klosowiak
- From the Department of Surgery, Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Michael J. Boctor
- From the Department of Surgery, Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Tariq Issa
- From the Department of Surgery, Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Seong Park
- From the Department of Surgery, Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Gregory A. Dumanian
- From the Department of Surgery, Division of Plastic Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
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Loh C, Tan L, Wijerathne S, Lee J, Wai L, Parameswaran R, Goh S, Oo AM, Lomanto D. Open versus laparoscopic intraperitoneal on-lay mesh repair: A comparison of outcomes in small ventral hernia. Asian J Surg 2023; 46:712-717. [PMID: 35842388 DOI: 10.1016/j.asjsur.2022.06.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/17/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The ideal surgical treatment of small ventral hernias (defect less than 4 cm) is still debatable. In our study, we sought to compare the outcomes of open versus laparoscopic intraperitoneal on-lay mesh (IPOM) repair in small ventral hernias. METHODS Patients with a single ventral hernia defect of less than 4 cm undergoing surgical mesh repair between January 2016 and September 2018 were prospectively registered for this study. The minimum follow-up duration was 12 months. Patient demographics, operative findings and regular post-operative follow-up details including recurrence rates and complications were recorded and analysed. RESULTS 41 patients underwent laparoscopic IPOM repair and 47 patients underwent open IPOM repair. The mean age for both groups is similar with no significant difference. The mean hernia defect size for the laparoscopic group is 2.8 cm (±0.8) whereas the mean hernia defect size for the open repair group is 2.1 cm (±0.4). The mean surgery duration for open IPOM repair was significantly shorter (59 min (±17) vs 74 min (±26); p = 0.001). There was no significant difference in the incidence of seroma formation and surgical site infections post-operatively. There was also no significant difference in both groups in terms of chronic pain and recurrence at 1-year follow-up. CONCLUSION Open IPOM repair for small ventral hernias may be superior to laparoscopic IPOM repair due to the shorter operative duration, single incision, and no additional risk of port-site hernias. There was no difference in chronic pain, wound infection and recurrence rate between the two groups.
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Affiliation(s)
- Clement Loh
- Department of Surgery, Alexandra Hospital, Singapore
| | - Lydia Tan
- Department of Surgery, Alexandra Hospital, Singapore.
| | - Sujith Wijerathne
- Department of Surgery, Alexandra Hospital, Singapore; Minimally Invasive Surgical Centre, National University Hospital Singapore
| | - James Lee
- Department of Surgery, Alexandra Hospital, Singapore
| | - Louis Wai
- Department of Surgery, Alexandra Hospital, Singapore
| | | | - Serene Goh
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Aung Myint Oo
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Davide Lomanto
- Department of Surgery, Alexandra Hospital, Singapore; Minimally Invasive Surgical Centre, National University Hospital Singapore
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Melkemichel M, Stjärne L, Bringman S, Widhe B. Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation. Hernia 2022; 26:1483-1489. [PMID: 34591212 PMCID: PMC9684217 DOI: 10.1007/s10029-021-02509-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/09/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Previous studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. An important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4 × 4 cm onlay-mesh for umbilical hernias ≤ 2 cm. METHODS A retrospective study was conducted at a single centre in Sweden on all umbilical hernia repairs during 2015-2019. The follow-up time was at least four months. Patients were identified using the hospital medical database. Repairs performed with suture or a sublay, ventral patch and laparoscopic mesh positioning were excluded. The patient's demographics, comorbidities, intra-and post-operative details were considered. The primary outcome was surgical site complications within 30 days. The secondary outcome was a recurrence. RESULTS 80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm. The median (range) follow-up time was 29.0 (4.3-50.1) months. The median age was 46 (26-76) years old. The median body mass index was 28 (19-38) kg/m2. The male to female ratio was 2:1. 4 patients were identified with a surgical site post-operative complication; three with seromas and one with a superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound openings bedside. There were no registered cases of recurrence. CONCLUSIONS Repairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess whether mesh can reduce recurrences in umbilical hernia repairs ≤ 2 cm.
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Affiliation(s)
- M Melkemichel
- Department of Surgery, Södertälje Hospital, 152 86, Södertälje, Sweden.
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - L Stjärne
- Department of Surgery, Södertälje Hospital, 152 86, Södertälje, Sweden
| | - S Bringman
- Department of Surgery, Södertälje Hospital, 152 86, Södertälje, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - B Widhe
- Department of Surgery, Södertälje Hospital, 152 86, Södertälje, Sweden
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
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10
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Lam K, Smith A, Slater K. Umbilical hernia: could it be the 'canary in the coal mine' for a more significant abdominal wall problem? ANZ J Surg 2022; 92:2517-2523. [PMID: 36036361 DOI: 10.1111/ans.17956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/07/2022] [Accepted: 07/14/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND A considerable proportion of incisional hernias presenting to this unit evolve following simple umbilical hernia repair. Our aim was to review our series of complex ventral hernia repairs and identify the frequency of this problem. Our secondary aim was to encourage surgeons to evaluate whether any of the factors that increase the risk of recurrent hernia may be present, prior to undertaking an umbilical hernia repair. METHODS Observational retrospective review of a prospectively maintained single-surgeon database of consecutive patients undergoing surgery for recurrent ventral hernia. Patients presenting with recurrence at the site of a previous umbilical hernia repair were identified and their demographic data collected and analysed. A review of the published literature was performed. Patient and surgeon factors contributing to recurrence were identified and discussed. RESULTS Of 386 patients undergoing surgery for a recurrent ventral hernial, 102 (26.4%) were initially managed as 'simple' umbilical hernias repaired with a mesh patch or primary suture repair. 71 (69.6%) patients had undergone one or more subsequent hernia repairs prior to referral to our unit with 16 (15.6%) having had three or more repairs prior to referral. CONCLUSION Recurrence rates after umbilical hernia repair are likely to be much higher than surgeons and patients appreciate. There are many aspects to consider in the repair of a 'simple' umbilical hernia and we seek promote a discussion amongst surgeons that umbilical hernias be assessed as a major abdominal wall condition and not relegated to minor surgery status.
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Affiliation(s)
- Ken Lam
- General Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Alison Smith
- Department of General Surgery, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Kellee Slater
- General Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of General Surgery, Greenslopes Private Hospital, Brisbane, Queensland, Australia
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11
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Sagar A, Tapuria N. An Evaluation of the Evidence Guiding Adult Midline Ventral Hernia Repair. Surg J (N Y) 2022; 8:e145-e156. [PMID: 35928547 PMCID: PMC9345681 DOI: 10.1055/s-0042-1749428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/01/2022] [Indexed: 11/09/2022] Open
Abstract
Purpose: Several guidelines have been published in recent years to guide the clinician in ventral hernia repair. This review distils this advice, critically assesses their evidence base, and proposes avenues for future study. Methods: A PUBMED search identified four guidelines addressing midline ventral hernia repair published by major surgical societies between 2016 and 2020. The studies used to inform the advice have been critically appraised, including 20 systematic reviews/meta-analyses, 10 randomized controlled trials, 32 cohort studies, and 14 case series. Results: Despite a lack of randomized controlled trials, case heterogeneity, and variation in outcome reporting, key themes have emerged. Preoperative computed tomography scan assesses defect size, loss of domain, and the likely need for component separation. Prehabilitation, frailty assessment, and risk stratification are beneficial in complex cases. Minimally invasive component separation techniques, Botox injection, and progressive pneumoperitoneum represent novel techniques to promote closure of large fascial defects. Rives-Stoppa sublay mesh repair has become the "gold" standard for open and minimally invasive repairs. Laparoscopic repair promotes early return to functional status. The enhanced-view totally extraperitoneal approach facilitates laparoscopic sublay mesh placement, avoiding mesh contact with viscera. Robotic techniques continue to evolve, although the evidence at present remains immature. Synthetic mesh is recommended for use in clean and clean-contaminated cases. However, optimism regarding the use of biologic and biosynthetic meshes in the contaminated setting has waned. Conclusions: Surgical techniques in ventral hernia repair have advanced in recent years. High-quality data has struggled to keep pace; rigorous clinical trials are required to support the surgical innovation.
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Affiliation(s)
- Alex Sagar
- General Surgery Department, Milton Keynes University Hospital, United Kingdom
| | - Niteen Tapuria
- General Surgery Department, Milton Keynes University Hospital, United Kingdom
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Al Sadairi AR, Durtette-Guzylack J, Renard A, Durot C, Thierry A, Kianmanesh R, Passot G, Renard Y. A simplified method to evaluate the loss of domain. Hernia 2022; 26:927-936. [PMID: 34341871 DOI: 10.1007/s10029-021-02474-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The treatment of giant incisional hernia (IH) with loss of domain (LOD, IHLD) is considerably challenging due to technical difficulties and subsequent post-operative complications. These post-operative risks may be anticipated by calculating the abdominal cavity (AC) volume (ACV) and the IH volume (IHV) on the preoperative CT-scans, using the AC and IH dimensions (Tanaka's method) or using tridimensional volumetry (Sabbagh's method). These techniques are often time-consuming and require specific softwares. The aim of the present study was to develop a simple method to rapidly obtain the LOD-ratio on the preoperative CT-Scan. METHODS The CT-scans (n = 89) of patients with IHLD were retrospectively studied. Several ratios were calculated using different parameters of the AC and the IH, including width, height and depth, the areas (axial and sagittal ellipse, as well as freehand sagittal surface areas) and these were compared with the reference methods of Sabbagh et al. and Tanaka et al. RESULTS: The LOD ratios calculated from the two reference methods gave similar results (ICC = 0.82, p < 0.0001). The new "R-ratios" (Reims-ratios) obtained from the IH and AC surface areas measured using the "freehand ROI" tool on sagittal view or roughly evaluated by an ellipse on axial view showed excellent correlation with both reference ratios (all ICC ≥ 0.71, p < 0.0001). CONCLUSION The LOD ratio may be quickly obtained by drawing two circles on the pre-operative CT scan ("R ratios") and available on the webpage https://romeo.univ-reims.fr/Rratio/ . This will certainly help surgeons to routinely anticipate the post-operative complications before IHLD repair.
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Affiliation(s)
- Abdul Rahman Al Sadairi
- Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Rue Cognac-Jay, 51092, Reims Cedex, France.
- Sultan Qaboos University, Muscat, Sultanate of Oman.
| | - Jules Durtette-Guzylack
- Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Rue Cognac-Jay, 51092, Reims Cedex, France
| | - Arnaud Renard
- Laboratory Liciis and ROMEO, University of Reims Champagne-Ardenne, Reims, France
| | - Carole Durot
- Department of Radiology, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Aurore Thierry
- Methodological Aid To Clinical Research Unit CHU Reims, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Reza Kianmanesh
- Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Rue Cognac-Jay, 51092, Reims Cedex, France
| | - Guillaume Passot
- Department of Digestive Surgery, Hopital Lyon Sud, Pierre Bénite, University of Lyon, Lyon, France
| | - Yohann Renard
- Department of General, Digestive and Endocrine Surgery, Robert-Debré University Hospital, University of Reims Champagne-Ardenne, Rue Cognac-Jay, 51092, Reims Cedex, France
- Laboratory Liciis and ROMEO, University of Reims Champagne-Ardenne, Reims, France
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Malysz Oyola AM, Faulkner J, Casas B, Hooks WB, W Hope W. Are Surgeons of the Abdominal Core Health Quality Collaborative Following Guidelines in Umbilical and Epigastric Hernia Repair? Am Surg 2022; 88:2163-2169. [PMID: 35642530 DOI: 10.1177/00031348221091960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Umbilical and epigastric hernias are among the top three most common hernia surgeries performed in the USA with varied techniques. The European and Americas Hernia Societies (EAHS) recently published guidelines for repair of umbilical and epigastric hernias. We evaluated how closely the general surgeons of the Abdominal Core Health Quality Collaborative (ACHQC) follow these guidelines and to identify areas for possible improvement. METHOD Data from patients undergoing elective and emergent umbilical or epigastric hernia repair from 2013 to 2021 were extracted from the ACHQC database. The procedures performed on eligible subjects were compared to those proposed by the EAHS guidelines. Data was reported as a percentage and a cutoff of 70% was selected to determine compliance. RESULTS Based on these criteria, 11,088 patients were included and most of the recommendations, including appropriate preoperative antibiotic dosing (96.1% umbilical; 97.2% epigastric), permanent mesh selection (umbilical 97.8%; 96.1 epigastric), mesh fixation with suture (83.6% umbilical; 75.5% epigastric), use of mesh for open repair of hernias greater than 1 cm (83.6 umbilical; 85.7 epigastric), and primary defect closure during open (98.6% umbilical; 97.5% epigastric) and laparoscopic (99.6% umbilical; 100% epigastric) repair, were met. DISCUSSION Surgeons of the ACHQC adhere to most of the published guidelines on umbilical and epigastric hernia repair. Further research is needed to reinforce or modify the existing recommendations. Standardization of surgical approach will facilitate additional research needed to improve procedural efficiency, while reducing negative outcomes and cost.
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Affiliation(s)
- Anna M Malysz Oyola
- Department of General Surgery, 24520Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Justin Faulkner
- Department of General Surgery, 24520Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Brandon Casas
- 6797University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - William B Hooks
- Department of General Surgery, 24520Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
| | - William W Hope
- Department of General Surgery, 24520Novant Health New Hanover Regional Medical Center, Wilmington, NC, USA
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OUP accepted manuscript. Br J Surg 2022; 109:408-410. [DOI: 10.1093/bjs/znac054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 11/13/2022]
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Melkemichel M, Bringman S, Granåsen G, Widhe B. SUMMER Trial: mesh versus suture repair in small umbilical hernias in adults-a study protocol for a prospective randomized double-blind multicenter clinical trial. Trials 2021; 22:411. [PMID: 34158088 PMCID: PMC8218273 DOI: 10.1186/s13063-021-05366-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background Small umbilical hernia repair is one of the most common surgical performances in general surgery. Yet, a gold standard procedure for the repair is still lacking today. There is an increasing evidence that mesh could be advantageous compared to suture repair in lowering recurrence rates. An additional important question remains with regard to the optimal anatomical positioning of the mesh. We hypothesize that the use of an onlay mesh in small umbilical hernia defects can reduce recurrence rates without increasing the complications compared to a simple suture repair. Methods A prospective, national, multicenter, randomized, double-blind clinical trial comparing a standardized 4 × 4 cm onlay mesh to a conventional suture repair will be conducted. A total of 288 patients with a primary elective umbilical hernia ≤ 2 cm from 7 participating Swedish surgical centers will be enrolled. Intraoperative randomization will take place using a centralized web-based system resulting in total allocation concealment. Stratification will be done by surgical site and by defect size. Trial participants and follow-up clinical surgeons will be blinded to the assigned allocation. The primary outcome assessed will be postoperative recurrence at 1 and 3 years. Secondary outcomes assessed will be postoperative complications at 30 days and pain 1 year after surgery. Discussion Currently, there has been no randomized clinical trial comparing the recurrence rates between an onlay mesh repair and a simple suture repair for small umbilical hernia defects. How to best repair a small umbilical hernia continues to be debated. This trial design should allow for a good assessment of the differences in recurrence rate due to the large sample size and the adequate follow-up. Surgeons’ concerns surrounding optimal anatomical positioning and fear for larger required dissections are understandable. A small onlay mesh may become an easy and safe method of choice to reduce recurrence rates. Guidelines for small umbilical hernia repairs have stressed the need for reliable data to improve treatment recommendations. We can expect that this trial will have a direct implication on small umbilical hernia repair standards. Trial registration ClinicalTrials.gov NCT04231071. Registered on 31 January 2020. SUMMER Trial underwent external peer review as part of the funding process.
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Affiliation(s)
- M Melkemichel
- Department of Surgery, Södertälje Hospital, Södertälje, Sweden. .,Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - S Bringman
- Department of Surgery, Södertälje Hospital, Södertälje, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - G Granåsen
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - B Widhe
- Department of Surgery, Södertälje Hospital, Södertälje, Sweden.,Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
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What is the reality in epigastric hernia repair?-a trend analysis from the Herniamed Registry. Hernia 2021; 25:1083-1094. [PMID: 33837884 DOI: 10.1007/s10029-021-02408-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The proportion of epigastric hernias in the total collective of all operated abdominal wall hernias is 3.6-6.9%. The recently published guidelines for treatment of epigastric hernias of the European Hernia Society and the Americas Hernia Society recommend the use of a mesh for defect size of ≥ 1 cm, i.e., a preperitoneal flat mesh technique for sizes 1-4 cm, and laparoscopic IPOM technique for defects > 4 cm and/or obesity. Against that background, this analysis of data from the Herniamed Registry now aims to explore trends in epigastric hernia repair. METHODS To detect trends, the perioperative outcome was calculated separately for the years 2010 to 2019 and the 1-year follow-up for the years 2010 to 2018 and significant differences were identified. Analysis was based on 25,518 primary elective epigastric hernia repairs. The rates of postoperative surgical complications, pain at rest, pain on exertion, chronic pain requiring treatment and recurrence associated with the various surgical techniques were calculated separately for each year. Fisher's exact test for unadjusted analysis between years was applied with Bonferroni adjustment for multiple testing. RESULTS The proportion of laparoscopic IPOM repairs declined from 26.0% in 2013 to 18.2% in 2019 (p < 0.001). Instead, the proportion of open sublay repairs rose from 16.5% to 21.8% (p < 0.001). That was also true for innovative techniques such as the EMILOS, MILOS, eTEP and preperitoneal flat mesh technique (8.3% vs 15.3%; p < 0.001). This change in indication for the various surgical techniques led to a significant improvement in the postoperative surgical complication rate (3.8% vs 1.9%; p < 0.001). CONCLUSION The trend is for epigastric hernia repair to be performed less often in laparoscopic IPOM technique and instead more often in open sublay technique or the new innovative techniques.
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Spencer Netto FAC, Mainprize M, Galant G, Szasz P. The incidence of occult paraumbilical hernias in patients undergoing primary umbilical hernia repair. Hernia 2021; 25:619-623. [PMID: 33743094 DOI: 10.1007/s10029-021-02392-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The primary goal of this study was to determine the incidence of occult paraumbilical hernias during open primary umbilical hernia repair. The secondary objective was to further characterize the clinical features of these patients and hernias. METHODS This was a retrospective chart review of patients undergoing primary umbilical hernia repair at Shouldice Hospital, from 2007 to 2017. Inclusion criteria were utilized to elucidate patients, where a concomitant occult paraumbilical hernia was found. Descriptive statistics were used throughout. RESULTS 5850 patients underwent primary umbilical hernia repair, 459 (7.85%) patients had concomitant primary umbilical and paraumbilical hernias. There was a preoperative suspicion/diagnosis of a paraumbilical hernia in 166 (2.8%) of these patients. In 293 (5.01%) patients who had open primary umbilical hernia repair, at least one associated occult paraumbilical defect was found during surgery. Most of umbilical and concomitant occult paraumbilical hernias were small and medium size defects. The great majority of the reported occult paraumbilical hernias were found in the supraumbilical position at a distance of 3 cm or less from the top of the umbilical defect. CONCLUSION The incidence of concomitant occult paraumbilical hernias in patients mildly overweight undergoing primary umbilical hernia repair is 5.01%, relevant to surgical decision-making. Since the great majority of these paraumbilical defects are superior to the umbilical defect, an adequate incision and dissection for at least 3 cm above the umbilical hernia may reduce the number of missed concomitant hernias and result in less presumed recurrences.
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Affiliation(s)
- F A C Spencer Netto
- General Surgeon at Shouldice Hospital, 7750 Bayview Ave., Thornhill, ON, L3T 7N2, Canada.
| | - M Mainprize
- Research Coordinator/Associate at Shouldice Hospital, Thornhill, ON, Canada
| | - G Galant
- General Surgeon at Shouldice Hospital, 7750 Bayview Ave., Thornhill, ON, L3T 7N2, Canada
| | - P Szasz
- General Surgeon at Shouldice Hospital, 7750 Bayview Ave., Thornhill, ON, L3T 7N2, Canada
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Adjunct botox to preoperative progressive pneumoperitoneum for incisional hernia with loss of domain: no additional effect but may improve outcomes. Hernia 2021; 25:1507-1517. [PMID: 33686553 DOI: 10.1007/s10029-021-02387-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/26/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Incisional hernia with loss of domain (IHLD) remains a surgical challenge. Its management requires complex approaches including specific preoperative and intra-operative techniques. This study focuses on the interest of adding preoperative botulinum toxin A (BTA) injection to preoperative progressive pneumoperitoneum (PPP), compared to PPP alone. MATERIAL Patients between January 2015 and March 2020 with IHLD who underwent pre-operative preparation were included. Their baseline characteristics were retrospectively analyzed, along with the characteristics of their incisional hernia before and after preparation including CT-scan volumetry. Intra-operative data, early post-operative outcomes, surgical site occurrences (SSOs) including surgical site infection (SSI) were recorded. RESULTS Four hundred and fifty (450) patients with incisional hernia were operated, including 41 patients (9.1%) with IHLD, 13 of which had both BTA and PPP, while 28 had PPP only. Both groups were comparable in term of patients and IHLD characteristics. Median increase in the volume of the abdominal cavity (VAbC) was + 55% for the entire population (+ 58.3% for the BTA-PPP group, p < 0.0001 and + 52.8% for the PPP-alone group, p < 0.0001) although the increase in volume was not different between the two groups (p = 0.99). Complete fascial closure was achieved in all patients. SSOs were more frequent in the PPP-alone group than in the BTA-PPP group (17 (60.7%) versus 3 (23.1%) patients, respectively, p = 0.043). CONCLUSION BTA and PPP are both useful in pre-operative preparation for IHLD. Combining both significantly increases the volume of abdominal cavity but associating BTA to PPP does not add any volumetric benefit but may decrease the post-operative SSO rate.
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Van den Dop LM, Sneiders D, Kleinrensink GJ, Jeekel HJ, Lange JF, Timmermans L. Infectious Complication in Relation to the Prophylactic Mesh Position: The PRIMA Trial Revisited. J Am Coll Surg 2021; 232:738-745. [PMID: 33601004 DOI: 10.1016/j.jamcollsurg.2021.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position. STUDY DESIGN Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure. RESULTS Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group. CONCLUSIONS Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.
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Affiliation(s)
| | - Dimitri Sneiders
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - Gert-Jan Kleinrensink
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Hans J Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Department of Surgery, IJsselland ziekenhuis, Capelle aan den Ijssel, The Netherlands
| | - Lucas Timmermans
- Department of Surgery, Department of Maasstad ziekenhuis, Rotterdam, The Netherlands
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Tao Z, Ordonez J, Huerta S. Hernia Size and Mesh Placement in Primary Umbilical Hernia Repair. Am Surg 2020; 87:1005-1013. [PMID: 33295197 DOI: 10.1177/0003134820971624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Umbilical hernia repair (UHR) using mesh has been demonstrated to significantly reduce recurrence. However, many surgical centers still perform tissue repair for UH. In the present study, we assessed a cohort of veteran patients undergoing a standard open tissue repair for primary UH to determine at which size recurrence may preclude tissue repair. A systematic review of the literature on hernia size recommendations to guide mesh placement was performed. METHODS A single-institution single-surgeon retrospective review of all patients undergoing open tissue repair of primary UH (n = 344) was undertaken at the VA North Texas Health Care System between 2005 and 2019. Guidelines for the preferred reporting items for systematic reviews and meta-analysis were undertaken for systematic review. RESULTS A literature review yielded inconsistent guidance for a specific hernia size to proceed with tissue vs. mesh repair. Our institutional review yielded 17 (4.9%) recurrences. Univariable analysis demonstrated recurrence to be associated with hernia size (2.8 vs. 2.3 cm; P = .04). However, on multivariable analysis, hernia size was demonstrated as not an independent predictor of recurrence [OR 1.47 (95% CI; .97-2.21; P = .07)]. CONCLUSION A review of the literature suggests mesh placement most commonly when the hernia size is > 2.0 cm; however, sources of evidence are heterogeneous in study design, patient population, and hernia types studied. Our institutional review demonstrated that primary UHs < 2.3 cm can successfully be treated via tissue repair. Larger, recurrent, incisional, and primary epigastric hernias may benefit from mesh placement.
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Affiliation(s)
- Zoe Tao
- Department of Surgery and VA North Texas Health Care System, Southwestern Medical Center, 25989University of Texas, Dallas, TX, USA
| | - Javier Ordonez
- Department of Surgery and VA North Texas Health Care System, Southwestern Medical Center, 25989University of Texas, Dallas, TX, USA
| | - Sergio Huerta
- Department of Surgery and VA North Texas Health Care System, Southwestern Medical Center, 25989University of Texas, Dallas, TX, USA
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Bredikhin M, Gil D, Rex J, Cobb W, Reukov V, Vertegel A. Anti-inflammatory coating of hernia repair meshes: a 5-rabbit study. Hernia 2020; 24:1191-1199. [PMID: 32026188 PMCID: PMC7223801 DOI: 10.1007/s10029-020-02122-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/04/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Polymeric mesh implantation has become the golden standard in hernia repair, which nowadays is one of the most frequently performed surgeries in the world. However, many biocompatibility issues remain to be a concern for hernioplasty, with chronic pain being the most notable post-operative complication. Oxidative stress appears to be a major factor in the development of those complications. Lack of material inertness in vivo and oxidative environment formed by inflammatory cells result in both mesh deterioration and slowed healing process. In a pilot in vivo study, we prepared and characterized polypropylene hernia meshes with vitamin E (α-tocopherol)-a potent antioxidant. The results of that study supported the use of vitamin E as potential coating to alleviate post-surgical inflammation, but the pilot nature of the study yielded limited statistical data. The purpose of this study was to verify the observed trend of the pilot study statistically. METHODS In this work, we conducted a 5-animal experiment where we have implanted vitamin E-coated and uncoated control meshes into the abdominal walls of rabbits. Histology of the mesh-adjacent tissues and electron microscopy of the explanted mesh surface were conducted to characterize host tissue response to the implanted meshes. RESULTS As expected, modified meshes exhibited reduced foreign body reaction, as evidenced by histological scores for fatty infiltrates, macrophages, neovascularization, and collagen organization, as well as by the surface deterioration of the meshes. CONCLUSION In conclusion, results indicate that vitamin E coating reduces inflammatory response following hernioplasty and protects mesh material from oxidative deterioration.
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Affiliation(s)
- M Bredikhin
- Department of Bioengineering, Clemson University, 301 Rhodes Hall, Clemson, SC, 29634, USA
| | - D Gil
- Department of Bioengineering, Clemson University, 301 Rhodes Hall, Clemson, SC, 29634, USA
| | - J Rex
- Department of Bioengineering, Clemson University, 301 Rhodes Hall, Clemson, SC, 29634, USA
| | - W Cobb
- Department of Surgery, The Hernia Center, Prisma Health, 2104 Woodruff rd., Greenville, SC, 29607, USA
| | - V Reukov
- Department of Bioengineering, Clemson University, 301 Rhodes Hall, Clemson, SC, 29634, USA
| | - A Vertegel
- Department of Bioengineering, Clemson University, 301 Rhodes Hall, Clemson, SC, 29634, USA.
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Köckerling F, Brunner W, Fortelny R, Mayer F, Adolf D, Niebuhr H, Lorenz R, Reinpold W, Zarras K, Weyhe D. Treatment of small (< 2 cm) umbilical hernias: guidelines and current trends from the Herniamed Registry. Hernia 2020; 25:605-617. [PMID: 33237505 DOI: 10.1007/s10029-020-02345-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/13/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3 cm. Suture repair should only be considered for small hernia defects of less than 1 cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2 cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2 cm) umbilical hernias over the past 10 years. METHODS Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented. RESULTS A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2 cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2 cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013. CONCLUSIONS A suture technique is still used to treat 75% of patients with small (< 2 cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.
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Affiliation(s)
- F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany.
| | - W Brunner
- Department of Surgery, Kantonspital St. Gallen, Rorschacher Str. 95, CH-9007, St. Gallen, Switzerland
| | - R Fortelny
- Department of General Surgery, Faculty of Medicine, Sigmund Freud University, Freudplatz 3, 1020, Vienna, Austria
| | - F Mayer
- Department of Surgery, Paracelsus Medical University Salzburg, University Hospital of Salzburg, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - D Adolf
- StatConsult GmbH, Halberstädter Strasse 40 a, 39112, Magdeburg, Germany
| | - H Niebuhr
- Hansechirurgie, Niebuhr Marleschki & Partner, Alte Holstenstr. 16, 21031, Hamburg, Germany
| | - R Lorenz
- Hernia Center 3+CHIRURGEN, Klosterstrasse 34/35, 13581, Berlin, Germany
| | - W Reinpold
- Wilhelmsburger Hospital Gross-Sand, Gross-Sand 3, 21107, Hamburg, Germany
| | - K Zarras
- Marien Hospital Düsseldorf, Rochusstrasse 2, 40479, Düsseldorf, Germany
| | - D Weyhe
- University Hospital of Visceral Surgery, Pius Hospital Oldenburg, Georgstrasse 12, 26121, Oldenburg, Germany
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Gu Y, Wang P, Li H, Tian W, Tang J. Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction. Am J Surg 2020; 222:86-98. [PMID: 33239177 DOI: 10.1016/j.amjsurg.2020.11.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common. DATA SOURCES With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results. CONCLUSIONS This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.
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Affiliation(s)
- Yan Gu
- Hernia and Abdominal Wall Disease Center, Shanghai Jiao Tong University, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Ping Wang
- Department of Hernia Surgery, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Hangyu Li
- Department of General Surgery, Fourth Hospital of China Medical University, Shenyang, 110000, China
| | - Wen Tian
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Jianxiong Tang
- Department of General Surgery, Huadong Hospital, Fudan University, Shanghai, 200040, China.
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24
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Köckerling F, Brunner W, Mayer F, Fortelny R, Adolf D, Niebuhr H, Lorenz R, Reinpold W, Zarras K, Weyhe D. Assessment of potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair: a registry-based multivariable analysis of 31,965 patients. Hernia 2020; 25:587-603. [PMID: 32951104 DOI: 10.1007/s10029-020-02305-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION How best to treat a small (< 2 cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1 cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1 cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors. METHODS The data of patients with primary elective umbilical hernia repair and defect size < 2 cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up. RESULTS 31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p < 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p < 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p < 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates. CONCLUSION Suture repair continues to be used for 78% of umbilical hernias with a defect < 2 cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).
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Affiliation(s)
- F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany.
| | - W Brunner
- Department of General, Visceral, Endocrine and Transplant Surgery, Rorschacher Kantonsspital St. Gallen, Str. 95, 9007, St. Gallen, Switzerland
| | - F Mayer
- Department of General, Visceral and Thoracic Surgery, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - R Fortelny
- Department of General Surgery, Hospital Ottakring, Montleartstrasse 37, 1160, Vienna, Austria.,Sigmund Freud University Vienna, Medical Faculty, Schnirchgasse 9a, 1030, Vienna, Austria
| | - D Adolf
- StatConsult GmbH, Halberstädter Strasse 40 a, 39112, Magdeburg, Germany
| | - H Niebuhr
- Hansechirurgie, Niebuhr Marleschki & Partner, Alte Holstenstr. 16, 21031, Hamburg, Germany
| | - R Lorenz
- Hernia Center 3 + CHIRURGEN, Klosterstrasse 34/35, 13581, Berlin, Germany
| | - W Reinpold
- Wilhelmsburger Hospital Gross-Sand, Gross-Sand 3, 21107, Hamburg, Germany
| | - K Zarras
- Marien Hospital Düsseldorf, Rochusstrasse 2, 40479, Düsseldorf, Germany
| | - D Weyhe
- Department of General and Visceral Surgery, Pius Hospital Oldenburg, University Hospital of Visceral Surgery, Georgstraße 12, 26121, Oldenburg, Germany
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25
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Barbato G, Rollo S, Maggioni C, Cianchi F, Coratti F. Laparoscopic diastasis recti abdominis and midline hernia repair. Minerva Surg 2020; 76:187-191. [PMID: 32773750 DOI: 10.23736/s2724-5691.20.08404-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Diastasis recti abdominis (DRA) is defined as an abnormally wide distance separates the two rectus muscles. Thinning and widening of the linea alba is an important risk factor for development midline hernia. In patient with DRA there is an increase rate of hernia recurrence. METHODS We perform a retrospective study to assess the outcome of laparoscopic intraperitoneal hernia repair and linea alba plication combined with mesh placement to obtain an adequate overlap of midline hernia associated to an abdominal wall support. The inclusion criteria were patients who has a clinical diagnosis of primary midline hernias of any size with associated diastasis recti. The exclusion criteria were incisional hernias, hernias outside of the midline. A total of 12 patients fulfilled the inclusion criteria. No complication was observed over the follow-up period. The rates for recurrence were 0% over the follow-up period. RESULTS Despite the limited data some assumptions can be drawn from this study. The presence of DRA and coexisting hernia involves a challenging choice of the surgical treatment. Whichever approach is taken, in order to achieve an effective correction, plication of the linea alba is required. The major goal of any abdominal wall repair is not only reduction of hernia sac and prevention of further herniation but also restoration of the integrity and restitution of abdominal wall functionality. CONCLUSIONS A laparoscopic approach to midline hernias associated to DRA is feasible and reproducible. It is necessary future prospective studies on larger numbers to improve knowledge on the management of DRA.
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Affiliation(s)
- Giuseppe Barbato
- Careggi University Hospital, University of Florence, Florence, Italy -
| | - Silvia Rollo
- Careggi University Hospital, University of Florence, Florence, Italy
| | - Cristina Maggioni
- Careggi University Hospital, University of Florence, Florence, Italy
| | - Fabio Cianchi
- Careggi University Hospital, University of Florence, Florence, Italy
| | - Francesco Coratti
- Division of Gastrointestinal Surgery, Careggi University Hospital, Florence, Italy
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26
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Kadakia N, Mudgway R, Vo J, Vong V, Seto T, Bortz P, Depew A. Long-Term Outcomes of Ventral Hernia Repair: An 11-Year Follow-Up. Cureus 2020; 12:e9523. [PMID: 32905150 PMCID: PMC7466072 DOI: 10.7759/cureus.9523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Ventral hernia repair (VHR) is one of the most common general surgery procedures; however, few studies with long-term follow-up of VHR outcomes exist. Methods: We performed a retrospective review of VHRs performed from 2000 to 2009 at a single institution. Our primary outcome was recurrence, and secondary outcomes were reoperations and complications including seroma, hematomas, abdominal wall abscess, wound infections, and mesh infections. Results: Our sample population (n=420; mean age 46.3±11.7 years) included 230 females (54.8%), and cases included laparoscopic (n=31; 7.5%), laparoscopic converted to open (n=7; 1.7%), and open (n=373, 90%). As compared to suture repairs, mesh repair was associated with lower rates of complications (25.7% vs 29.5%, p=0.10) and recurrence (12.8% vs 15.2%, p=0.67). Laparoscopic repairs had lower rates of complications than open repairs (25% vs 26.8%; p=0.70) but similar rates of recurrence (13.8% and 13.6%; p=0.53). After logistic regression, obesity, chronic obstructive pulmonary disease, component separation technique, and prolonged operating time (>75th percentile) were associated with increased complications. Conclusion: Obesity is a modifiable risk factor and must be addressed in patients undergoing VHRs. Mesh repair does not increase the risk of adverse long-term outcomes and may be performed safely in patients undergoing VHR.
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Affiliation(s)
- Nikita Kadakia
- Surgery, University of California Riverside School of Medicine, Riverside, USA
| | - Ross Mudgway
- General Surgery, Loma Linda University School of Medicine, Loma Linda, USA
| | - Jonathan Vo
- General Surgery, Riverside University Health System Medical Center, Riverside, USA
| | - Vinson Vong
- Emergency Medicine, University of California Riverside School of Medicine, Riverside, USA
| | | | - Pascal Bortz
- General Surgery, Riverside University Health System Medical Center, Riverside, USA
| | - Aron Depew
- Surgery, Beaver Medical Group, Redlands, USA
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27
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Kler A, Wilson P. Total endoscopic-assisted linea alba reconstruction (TESLAR) for treatment of umbilical/paraumbilical hernia and rectus abdominus diastasis is associated with unacceptable persistent seroma formation: a single centre experience. Hernia 2020; 24:1379-1385. [PMID: 32691174 DOI: 10.1007/s10029-020-02266-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/14/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Umbilical hernia with concomitant rectus abdominus diastasis (RAD) is potentially associated with higher recurrence. Open and laparoscopic techniques have already been described, however, recent endoscopic methods show great promise. Therefore, our aim was to establish the risks and benefits of performing total endoscopic-assisted linea alba reconstruction (TESLAR). METHODS A retrospective review from 28/03/2018 to 01/05/2019 of TESLAR patients was undertaken. Data collected included medical history, operative notes and postoperative course. Statistical analyses were performed using univariate analysis. Operative technique began with a subcutaneous dissection from the lateral borders of anterior rectus sheath, lower costal margin, and pubic bone. The defect was defined and subsequently reduced. Anterior rectus sheath was subsequently plicated and if a mesh was inserted, an on-lay mesh was placed. RESULTS 21 patients were identified with an 8:13 male to female ratio. Mean age and BMI were 53.1 and 29.7, respectively. 19/21 patients reported post-operative complications requiring reintervention. 17/21 patients had a seroma, all requiring draining with a minority (5/21) requiring formal excision. Univariate analysis showed age (p < 0.001), BMI (p < 0.001) and female gender (p = 0.022) were significantly associated with repeated number of seroma aspirations. CONCLUSION TESLAR is associated with high rates of seroma and reintervention, including revisional surgery. Open repair should be considered as an alternative strategy for hernia and RAD repair.
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Affiliation(s)
- Aaron Kler
- Department of General Surgery, Royal Lancaster Infirmary, University of Morecambe Bay Hospitals NHS Trust, Lancaster, UK.
| | - Paul Wilson
- Department of General Surgery, Royal Lancaster Infirmary, University of Morecambe Bay Hospitals NHS Trust, Lancaster, UK
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Abstract
There are conflicting views regarding techniques for repair of small umbilical hernias (UHs). Here, we compare the recurrence rate in primary repair with that reported for mesh repair by examining a single surgeon's practice at a large medical center with a comprehensive electronic medical record. A six-year retrospective review of primary UH repairs between January 2012 and December 2017 at Kaiser Permanente Los Angeles Medical Center was undertaken. Patients were identified through a database search of the electronic medical record. The primary endpoint of UH recurrence was examined; median follow-up was 3.4 years. Primary, elective UH repair was performed in 244 patients; 71 per cent of hernias were small (<2 cm). The total number of recurrences was seven (3%). The t test analysis showed significant differences in the average size of hernia defects between those with recurrences (2 cm) and those without (1.4 cm), P < 0.05. Primary repair affords low infection and recurrence rates, comparable to those reported for mesh repair. Our single-surgeon/large-volume study contributes to the evidence that primary UH repair is a safe and durable method, with low risk of recurrence. The use of absorbable monofilament suture, and selection for lower BMI and smaller hernia sizes proved to be effective.
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29
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Goldwag JL, Wilson LR, Ivatury SJ, Pauli EM, Tsapakos MJ, Wilson MZ. Stoma closure and reinforcement (SCAR): A study protocol for a pilot trial. Contemp Clin Trials Commun 2020; 19:100582. [PMID: 32577580 PMCID: PMC7300121 DOI: 10.1016/j.conctc.2020.100582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 05/21/2020] [Accepted: 06/07/2020] [Indexed: 12/21/2022] Open
Abstract
A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.
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Affiliation(s)
- Jenaya L Goldwag
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Lauren R Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Srinivas J Ivatury
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Eric M Pauli
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michael J Tsapakos
- Department of Radiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Matthew Z Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Henriksen NA, Montgomery A. Author response to: Comment on: Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg 2020; 107:e216. [PMID: 32342486 DOI: 10.1002/bjs.11576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/10/2020] [Indexed: 11/08/2022]
Affiliation(s)
- N A Henriksen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - A Montgomery
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
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31
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Kaufmann R, Halm JA, Lange JF. Comparing apples and oranges will not guide treatment the right way in umbilical hernia repair: use either level-1 evidence or guidelines. Hernia 2020; 25:821-822. [PMID: 32323038 DOI: 10.1007/s10029-020-02193-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/09/2020] [Indexed: 11/30/2022]
Affiliation(s)
- R Kaufmann
- Department of Radiology, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA, The Hague, The Netherlands. .,Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - J A Halm
- Department of Traumasurgery, Amsterdam University Medical Centres, Location AMC, Amsterdam, The Netherlands
| | - J F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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The power of level-1 evidence in umbilical hernia repair: mesh repair is supported by strong evidence. Hernia 2020; 25:247-248. [PMID: 32253521 DOI: 10.1007/s10029-020-02185-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022]
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Is mesh always necessary in every small umbilical hernia repair? Comparison of standardized primary sutured versus patch repair: retrospective cohort study. Hernia 2020; 25:571-577. [PMID: 32189143 PMCID: PMC8197705 DOI: 10.1007/s10029-020-02170-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 03/06/2020] [Indexed: 12/13/2022]
Abstract
Purpose A retrospective analysis was carried out to compare the results of patch repair using ready-made, synthetic mesh (PR) and sutured repair (SR) based on standard protocols. The accumulated recurrence rate was accepted as the primary outcome. Pain at rest and during exercise, cosmetic effect and treatment satisfaction were chosen as the secondary endpoints. Methods Adult patients after elective, open surgical repair of a single, primary umbilical hernia < 2 cm in diameter were included. Patients with incarceration or strangulation, after previous umbilical hernia repair or other abdominal surgical interventions were excluded. In the SR group, single-layer sutures were placed using the short-stitch technique. In PR group, a 6.3-mm ready-made Parietene Ventral Patch (Medtronic) was used. Results 161 patients (104 in PR and 57 in SR groups) were included in the study (22 months follow-up). Nine recurrences were observed [six in PR (5.8%) and three in SR group (5.2%)]. In PR group, three patients (2.9%) reported complaints at rest and none in SR group, while 18 patients (17.3%) in PR group reported pain during exercises and 7 (12.3%) in SR group. Conclusion For the smallest umbilical hernias, the use of dense fascia suturing (short-stitch technique) may be an effective alternative to patch repair techniques in patients with no additional risk factors for recurrence. The mesh patch repair method is associated with a significantly higher risk of postsurgical pain. Diastasis recti is a factor favoring umbilical hernia recurrence after both pure tissue repair and patch repair.
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Harpain F, Wimmer K, Dawoud C, Ogrodny P, Stift A. Short-term outcome after ventral hernia repair using self-gripping mesh in sublay technique - A retrospective cohort analysis. Int J Surg 2020; 75:47-52. [PMID: 31991243 DOI: 10.1016/j.ijsu.2020.01.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/10/2020] [Accepted: 01/18/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hernia repair in sublay technique is widely accepted for ventral hernias, as it appears to be advantageous in terms of complication and recurrence rates. Self-gripping meshes are increasingly used for hernia repair with retromuscular mesh positioning. However, real-life data on the safe use in that specific indication are still lacking. The purpose of this study is the evaluation of short-term postoperative outcome of self-gripping versus conventional non-self-gripping meshes in sublay hernia repair. MATERIALS AND METHODS This retrospective analysis assessed patients undergoing ventral hernia repair in sublay technique between January 2011 and July 2018 at the Department of Surgery, Medical University of Vienna. 244 consecutive patients were eligible for final analysis. Patients were grouped according to the utilized mesh. Baseline characteristics and peri-as well as postoperative outcome was assessed. RESULTS There was no significant difference in baseline characteristics between the two groups. Median follow-up was 11 months (IQR 3-30). The overall complication rate (28.3% versus 13.7%, p = 0.005) due to an increased rate of seromas (17.3% versus 6.8%, p = 0.013) and surgical site infections (12.6% versus 4.3%, p = 0.021) was significantly higher in patients with a self-gripping mesh. Significantly more patients with a self-gripping mesh needed a surgical intervention (21.3% versus 9.4%, p = 0.011). CONCLUSION In sublay ventral hernia repair, the use of self-gripping meshes is associated with a higher overall complication rate and an increased rate of complication-associated surgical interventions when compared to non-self-gripping mesh placements.
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Affiliation(s)
- Felix Harpain
- Department of Surgery, Division of General Surgery, Medical University Vienna, Austria
| | - Kerstin Wimmer
- Department of Surgery, Division of General Surgery, Medical University Vienna, Austria
| | - Christopher Dawoud
- Department of Surgery, Division of General Surgery, Medical University Vienna, Austria
| | - Philipp Ogrodny
- Department of Surgery, Division of General Surgery, Medical University Vienna, Austria
| | - Anton Stift
- Department of Surgery, Division of General Surgery, Medical University Vienna, Austria.
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Mesh OR Patch for Hernia on Epigastric and Umbilical Sites (MORPHEUS-Trial): The Complete Two-year Follow-up. Ann Surg 2020; 270:33-37. [PMID: 30339623 DOI: 10.1097/sla.0000000000003086] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this trial was to identify a superior method for umbilical and epigastric hernia repair in terms of complications. Complications such as an extended operation duration, additional use of painkillers, reoperation, infection, seroma, extended wound care, extended hospitalization, and early recurrence were reported according to the Clavien-Dindo grading system. SUMMARY BACKGROUND DATA Over the years mesh repair is proven the gold standard for umbilical and epigastric hernias. The question remains, which mesh should be used? METHODS In this randomized controlled, multicenter trial, all patients ≥ 18 years with a single, symptomatic, and primary small umbilical or epigastric hernia qualified for inclusion. Flat preperitoneal polypropylene mesh repair was compared with patch repair (PROCEED Ventral Patch) (PVP). RESULTS A total of 352 patients were randomized; 348 patients received the intervention (n = 177 PVP vs n = 171 mesh). One out of 4 suffered from any kind of complication within 2 years postoperative (27.6%). A significant difference in complications was seen, in favor of polypropylene mesh repair (P = 0.044, 22.1% mesh vs 32.5% PVP). Reoperation was performed in 19 PVP operated patients (10.7%) versus 7 patients with polypropylene mesh repair (4.0%, P = 0.021).No significant differences were seen in recurrences (n = 13, 8.4% PVP vs n = 6, 4.1% mesh, P = 0.127). CONCLUSIONS In small epigastric and small umbilical hernia repair a flat polypropylene mesh repair was associated with a lower complication rate than PVP repair. No differences in recurrence rates were seen. Combining all complications, the preperitoneal positioned flat polypropylene mesh performed better.
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36
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Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Simons MP. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg 2020; 107:171-190. [PMID: 31916607 DOI: 10.1002/bjs.11489] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/31/2019] [Accepted: 12/02/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias. METHODS The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019. RESULTS Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity. CONCLUSION This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.
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Affiliation(s)
- N A Henriksen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - A Montgomery
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - R Kaufmann
- Erasmus University Medical Centre, Rotterdam, the Netherlands.,Tergooi, Hilversum, the Netherlands
| | - F Berrevoet
- Department of General and Hepatopancreatobiliary Surgery, Ghent University Hospital, Ghent, Belgium
| | - B East
- Third Department of Surgery at Motol University Hospital, First and Second Faculty of Medicine at Charles University, Prague, Czech Republic
| | - J Fischer
- University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - W Hope
- New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - D Klassen
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - R Lorenz
- Praxis 3+ Chirurgen, Berlin, Germany
| | - Y Renard
- Department of Digestive Surgery, Robert Debré University Hospital, Reims, France
| | - M A Garcia Urena
- Henares University Hospital, Faculty of Health Sciences, Francisco de Vitoria University, Madrid, Spain
| | - M P Simons
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
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Primary uncomplicated midline ventral hernias: factors that influence and guide the surgical approach. Hernia 2019; 23:873-883. [DOI: 10.1007/s10029-019-02051-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/09/2019] [Indexed: 12/24/2022]
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Donovan K, Denham M, Kuchta K, Denham W, Linn JG, Haggerty SP, Carbray J, Ujiki M. Predictors for recurrence after open umbilical hernia repair in 979 patients. Surgery 2019; 166:615-622. [DOI: 10.1016/j.surg.2019.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/08/2019] [Accepted: 04/16/2019] [Indexed: 12/19/2022]
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Primary non-complicated midline ventral hernia: overview of approaches and controversies. Hernia 2019; 23:885-890. [PMID: 31493055 DOI: 10.1007/s10029-019-02037-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 08/18/2019] [Indexed: 10/26/2022]
Abstract
Umbilical hernias and epigastric hernias are some of the most common hernias in the world. Umbilical and epigastric hernia defects can range from small (<1 cm) to very large/complex hernias, and treatment options should be tailored to the clinical situation. Repair techniques include open, laparoscopic, and robotics options, each with advantages and disadvantages. A mesh-based repair is indicated in most cases due to having fewer associated recurrences. Overall outcomes are favorable following umbilical and epigastric hernia repairs; however, some patients have chronic complaints mostly related to recurrences. This report is an overview of available techniques for repair of umbilical and epigastric hernias. It also discusses ongoing controversies related to umbilical and epigastric hernia repairs, the limitations of available literature, and the need for future research.
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Blonk L, Civil YA, Kaufmann R, Ket JCF, van der Velde S. A systematic review on surgical treatment of primary epigastric hernias. Hernia 2019; 23:847-857. [PMID: 31422492 PMCID: PMC6838029 DOI: 10.1007/s10029-019-02017-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/18/2019] [Indexed: 11/30/2022]
Abstract
Objective In this systematic review, we evaluated all literature reporting on the surgical treatment of primary epigastric hernias, primarily focusing on studies comparing laparoscopic and open repair, and mesh reinforcement and suture repair. Methods A literature search was conducted in Embase.com, PubMed and the Cochrane Library up to 24 April 2019. This review explicitly excluded literature on incisional hernias, ventral hernias not otherwise specified, and isolated (para)umbilical hernias. Primary outcome measures of interest were early and late postoperative complications. Results We obtained a total of 8516 articles and after a strict selection only seven retrospective studies and one randomised controlled trial (RCT) on treatment of primary epigastric hernia were included. In one study (RCT) laparoscopic repair led to less postoperative pain (VAS) compared to open repair (3.6 versus 2.4, p < 0.001). No significant differences in early postoperative complications and recurrences were observed. Mesh reinforcement was associated with lower recurrence rates than suture repair in two studies (2.2% versus 5.6%, p = 0.001 and 3.1% versus 14.7%, p = 0.0475). This result was not sustained in all studies. No differences were observed in early postoperative complications after mesh or suture repair. Conclusions This review demonstrated that studies investigating surgical treatment of primary epigastric hernias are scarce. The best available evidence suggests that mesh reinforcement in primary epigastric hernia repair possibily leads to less recurrences and that laparoscopic repair leads to less postoperative pain. Due to the high risk of selection bias of included studies and heterogenic study populations, no clear recommendations can be conducted. High-quality studies with well-defined patient groups and clear endpoints, primarily focusing on primary epigastric hernias, are mandatory. Electronic supplementary material The online version of this article (10.1007/s10029-019-02017-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L Blonk
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Y A Civil
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - R Kaufmann
- Department of Surgery, Tergooi, Van Riebeeckweg 212, 1213 XZ, Hilversum, The Netherlands
| | - J C F Ket
- Medical Library, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - S van der Velde
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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Berrevoet F, Doerhoff C, Muysoms F, Hopson S, Muzi MG, Nienhuijs S, Kullman E, Tollens T, Schwartz M, Leblanc K, Velanovich V, Jørgensen LN. Open ventral hernia repair with a composite ventral patch - final results of a multicenter prospective study. BMC Surg 2019; 19:93. [PMID: 31311545 PMCID: PMC6633695 DOI: 10.1186/s12893-019-0555-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/03/2019] [Indexed: 01/08/2023] Open
Abstract
Background This study assessed clinical outcomes, including safety and recurrence, from the two-year follow-up of patients who underwent open ventral primary hernia repair with the use of the Parietex™ Composite Ventral Patch (PCO-VP). Methods A prospective single-arm, multicenter study of 126 patients undergoing open ventral hernia repair for umbilical and epigastric hernias with the PCO-VP was performed. Results One hundred twenty-six subjects (110 with umbilical hernia and 16 with epigastric hernia) with a mean hernia diameter of 1.8 cm (0.4–4.0) were treated with PCO-VP. One hundred subjects completed the two-year study. Cumulative hernia recurrence was 3.0% (3/101; 95%CI: 0.0–6.3%) within 24 months. Median Numeric Rating Scale pain scores improved from 2 [0–10] at baseline to 0 [0–3] at 1 month (P < 0.001) and remained low at 24 months 0 [0–6] (P < 0.001). 99% (102/103) of the patients were satisfied with their repair at 24 months postoperative. Conclusions The use of PCO-VP to repair primary umbilical and epigastric defects yielded a low recurrence rate, low postoperative and chronic pain, and high satisfaction ratings, confirming that PCO-VP is effective for small ventral hernia repair in the two-year term after implantation. Trial registration The study was registered publically at clinicaltrials.gov (NCT01848184 registered May 7, 2013).
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Affiliation(s)
- F Berrevoet
- Department of General and Hepatopancreatobiliary Surgery, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - C Doerhoff
- Surgicare of Missouri, Jefferson City, MO, USA
| | - F Muysoms
- Department of Surgery AZ Maria Middelares, Ghent, Belgium
| | - S Hopson
- Bon Secours Hernia Center, Mary Immaculate Hospital, Newport News, VA, USA
| | - M G Muzi
- University Hospital Tor Vergata, Rome, Italy
| | - S Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - E Kullman
- HELSA Specialist Center, Linköping, Sweden
| | - T Tollens
- Imelda Hospital -General Surgery Imelda Hospital, Bonheiden, Belgium
| | - M Schwartz
- Monmouth Medical Center, Long Branch, NJ, USA
| | - K Leblanc
- Our Lady of Lakes Regional Medical Center, Baton Rouge, LA, USA
| | - V Velanovich
- Division of General Surgery, University of South Florida, Tampa General Hospital, Tampa, FL, USA
| | - L N Jørgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Claus CMP, Malcher F, Cavazzola LT, Furtado M, Morrell A, Azevedo M, Meirelles LG, Santos H, Garcia R. SUBCUTANEOUS ONLAY LAPAROSCOPIC APPROACH (SCOLA) FOR VENTRAL HERNIA AND RECTUS ABDOMINIS DIASTASIS REPAIR: TECHNICAL DESCRIPTION AND INITIAL RESULTS. ACTA ACUST UNITED AC 2018; 31:e1399. [PMID: 30539974 PMCID: PMC6284377 DOI: 10.1590/0102-672020180001e1399] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/24/2018] [Indexed: 12/29/2022]
Abstract
Background: Diastasis of the rectus abdominis muscles (DMRA) is frequent and may be
associated with abdominal wall hernias. For patients with redudant skin,
dermolipectomy and plication of the diastasis is the most commonly used
procedure. However, there is a significant group of patients who do not
require skin resection or do not want large incisions. Aim: To describe a “new” technique (subcutaneous onlay laparoscopic approach -
SCOLA) for the correction of ventral hernias combined with the DMRA
plication and to report the initial results of a case series. Method: SCOLA was applied in 48 patients to correct ventral hernia concomitant to
plication of DMRA by pre-aponeurotic endoscopic technique. Results: The mean operative time was 93.5 min. There were no intra-operative
complications and no conversion. Seroma was the most frequent complication
(n=13, 27%). Only one (2%) had surgical wound infection. After a median
follow-up of eight months (2-19), only one (2%) patient presented recurrence
of DMRA and one (2%) subcutaneous tissue retraction/fibrosis. Forty-five
(93.7%) patients reported being satisfied with outcome. Conclusion: The SCOLA technique is a safe, reproducible and effective alternative for
patients with abdominal wall hernia associated with DMRA.
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Affiliation(s)
- Christiano Marlo Paggi Claus
- Department of Surgical Clinic and Mini Invasive Surgery - Jacques Perissat Institute, Positivo University, Curitiba, PR, Brazil
| | - Flavio Malcher
- Celebration Health Florida Hospital, Celebration, FL, USA
| | - Leandro Totti Cavazzola
- Service of General Surgery, Hospital de Clínicas, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo Furtado
- Service of General and Laparoscopic Surgery, Pitangueiras Hospital, Jundiaí, SP, Brazil
| | - Alexander Morrell
- Service of General Surgery, Einstein Hospital, São Paulo, SP, Brazil
| | - Mauricio Azevedo
- Service of General Surgery and Digestive System, Mandaqui Hospital, São Paulo, SP, Brazil
| | | | - Heitor Santos
- Digestive Surgery Service, Americas Medical Services / Pro-Cardiac Hospital, Rio de Janeiro, RJ, Brazil
| | - Rodrigo Garcia
- Department of Digestive System Surgery, Municipal Public Server Hospital, São Paulo, SP, Brazil
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Bisgaard T, Kaufmann R, Christoffersen MW, Strandfelt P, Gluud LL. Lower Risk of Recurrence After Mesh Repair Versus Non-Mesh Sutured Repair in Open Umbilical Hernia Repair: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Scand J Surg 2018; 108:187-193. [PMID: 30488767 DOI: 10.1177/1457496918812208] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The use of mesh repair in a small- or middle-sized umbilical hernia remains controversial, and evidence is based on only few and small heterogeneous randomized trials. The primary aim was to assess differences, if any, in recurrence (clinical and reoperation), and secondary aim was to assess differences in infections, seroma formation, hematomas, chronic pain, cosmetic result, and quality of life. METHOD A systematic review (predefined search strategy) and meta-analyses were conducted based on pre-study strict and well-defined methodology. The literature search was completed on 1 January 2018. The study protocol was registered in PROSPERO. RESULTS Five randomized controlled trials were identified (mesh repair, n = 326 versus non-mesh sutured repair, n = 330) and 602 records were excluded. Randomized controlled trials included patients with defect diameters of ⩾1 to 4 cm. Mesh repair reduced the risk of recurrence compared with sutured repair with a relative risk of 0.28 (95% confidence interval = 0.13-0.58, I2 = 0%, number needed to treat = 13 patients). Additional analyses found no differences between the two surgical techniques regarding infection (relative risk = 0.80, 95% confidence interval = 0.36-1.79), seroma formation (relative risk = 1.38, 95% confidence interval = 0.57-3.32), or hematomas (relative risk = 0.55, 95% confidence interval = 0.23-1.30). Lack of sufficient data precluded meta-analysis evaluating risk of seroma formation, hematomas, chronic pain, cosmetic result, and quality of life. CONCLUSION Mesh repair is recommended for umbilical hernia of ⩾1 to 4 cm. More evidence is needed for the optimal placement of the mesh (sublay or onlay) and the role of mesh in patients with an umbilical hernia <1 cm.
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Affiliation(s)
- T Bisgaard
- 1 Gastrounit, Surgical Division, Centre for Surgical Research (CSR), Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - R Kaufmann
- 2 Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M W Christoffersen
- 1 Gastrounit, Surgical Division, Centre for Surgical Research (CSR), Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - P Strandfelt
- 1 Gastrounit, Surgical Division, Centre for Surgical Research (CSR), Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - L L Gluud
- 3 Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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Köhler G, Fischer I, Kaltenböck R, Schrittwieser R. Minimal Invasive Linea Alba Reconstruction for the Treatment of Umbilical and Epigastric Hernias with Coexisting Rectus Abdominis Diastasis. J Laparoendosc Adv Surg Tech A 2018; 28:1223-1228. [DOI: 10.1089/lap.2018.0018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Gernot Köhler
- Department of General and Visceral Surgery, Congregation Hospital (Sisters of Charity), Linz, Austria
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
- Academic Teaching Hospital of the Medical Universities Vienna, Graz, Austria
| | - Ines Fischer
- Department of General and Visceral Surgery, Congregation Hospital (Sisters of Charity), Linz, Austria
- Academic Teaching Hospital of the Medical Universities Vienna, Graz, Austria
| | - Richard Kaltenböck
- Department of General and Visceral Surgery, Congregation Hospital (Sisters of Charity), Linz, Austria
- Academic Teaching Hospital of the Medical Universities Vienna, Graz, Austria
| | - Rudolf Schrittwieser
- Department of General Surgery, Landeskrankenhaus Hochsteiermark, Bruck an der Mur, Austria
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Mesh Versus Patch Repair for Epigastric and Umbilical Hernia (MORPHEUS Trial); One-Year Results of a Randomized Controlled Trial. World J Surg 2018; 42:1312-1320. [PMID: 29026977 DOI: 10.1007/s00268-017-4297-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
DESIGN This trial is a randomized controlled, patient-blinded, multicentre, superiority trial. METHODS All patients ≥18 years with a single, symptomatic and primary umbilical or epigastric hernia (<2 fingers) qualified for participation in the study. Flat polypropylene mesh repair was compared to patch repair (PROCEED® Ventral Patch) (PVP). The objective of this trial was to identify a superior method for umbilical and epigastric hernia repair in terms of complication rates. RESULTS A total of 352 patients were randomized in this trial; 348 patients received the intervention (n = 177 PVP vs. n = 171 mesh). No peri-operative complications occurred. PVP placement was significantly faster compared to mesh placement (30 min, SD 11 vs. 35 min, SD 11) and was scored as an easier procedure. At 1-month follow-up, 76 patients suffered any kind of complication. There was no significant difference in the proportion of complications (24.9% for PVP and 18.7% for mesh, p = 0.195). A significant difference was seen in re-operation rate within 1 month, significantly less early re-operations in the mesh group (0.0 vs. 2.8%, p = 0.027). After 1-year follow-up, no significant differences are seen in recurrence rates (n = 13, 7.8% PVP vs. n = 5, 3.3% mesh, p = 0.08). CONCLUSIONS Both mesh and PVP had a comparable amount of reported complications. There was a significantly higher incidence of early re-operations due to early complications in the PVP group. No differences were seen in infection rates and the need for antibiotic treatment. No significant difference was seen in the recurrence rates. REGISTRATION This trial was registered in the Dutch Trail Registry (NTR) NTR2514NL33995.060.10. [12].
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46
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Xie Y, Song Y, Ma D, Jian F, Zhang S, Lu A, Wang Y, Lei W. Retrospective analysis of smaller than 3-cm umbilical hernia repair with the lightweight macroporous mesh. Medicine (Baltimore) 2018; 97:e12245. [PMID: 30200154 PMCID: PMC6133605 DOI: 10.1097/md.0000000000012245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/10/2018] [Indexed: 02/05/2023] Open
Abstract
There is evidence that mesh repair for primary umbilical hernias results in fewer recurrences and similar wound complication rates compared to tissue repair. Various devices and surgical approaches are used in umbilical hernia repair. The ULTRAPRO PLUG (UPP) has been adopted for inguinal hernias and femoral hernias with excellent results. However, there are few reports on the use of UPP for umbilical hernia repair. Thus, the aim of this study was to evaluate efficacy and safety in the treatment of smaller than 3-cm umbilical hernias using the UPP.The medical records of 123 patients who underwent umbilical hernia repair using the UPP between October 2011 and September 2017 were reviewed. All patients were followed-up after 1 month and later in 2018. Demographics, surgical information, and immediate postoperative and long-term complications were assessed.Out of 123 patients, there were 37 male and 86 female patients with a mean age of 50.6 years. The median duration of hernia surgery was 20.5 min (range, 12-34), and 109 (88.6%) patients underwent day surgery. The median defect diameter was 1.4 cm (range, 0.5-3). No mortality or major complications occurred during the perioperative period. Long-term follow-up data were available for 107 (87.0%) patients. The median follow-up duration was 33 months (range, 5-76 months). Early postoperative complications included 1 case of seroma, 2 cases of fat liquefaction, and 1 case of superficial surgical site infection. During follow-up, there were 2 recurrences, 1 case of chronic mesh infection, and 2 patients with chronic postoperative pain.The ULTRAPRO PLUG offers a simple and quick means of repairing smaller than 3-cm umbilical hernias with lower recurrence rates and fewer postoperative complications.
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Affiliation(s)
- Yanyan Xie
- Department of Gastrointestinal Surgery, Hernia Center
| | - Yinghan Song
- Department of Day Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Dongyang Ma
- Department of Gastrointestinal Surgery, Hernia Center
| | - Fushun Jian
- Department of Gastrointestinal Surgery, Hernia Center
| | - Sen Zhang
- Department of Gastrointestinal Surgery, Hernia Center
| | - Anqing Lu
- Department of Gastrointestinal Surgery, Hernia Center
| | - Yong Wang
- Department of Gastrointestinal Surgery, Hernia Center
| | - Wenzhang Lei
- Department of Gastrointestinal Surgery, Hernia Center
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Rhemtulla IA, Messa CA, Enriquez FA, Hope WW, Fischer JP. Role of Prophylactic Mesh Placement for Laparotomy and Stoma Creation. Surg Clin North Am 2018; 98:471-481. [PMID: 29754617 DOI: 10.1016/j.suc.2018.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Incisional and parastomal hernias are a cause of significant morbidity and have a substantial effect on quality of life and economic costs for patients and hospital systems. Although many aspects of abdominal hernias are understood, prevention is a feature that is still being realized. This article reviews the current literature and determines the utility of prophylactic mesh placement in prevention of incisional and parastomal hernias.
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Affiliation(s)
- Irfan A Rhemtulla
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, South Pavilion - 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Charles A Messa
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, South Pavilion - 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Fabiola A Enriquez
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, South Pavilion - 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - William W Hope
- Department of Surgery, New Hanover Regional Medical Center, 1725 New Hanover Medical Park Drive, Wilmington, NC 28403, USA
| | - John P Fischer
- Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, South Pavilion - 14th Floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Abstract
Umbilical hernias are ubiquitous, and surgery is indicated in symptomatic patients. Umbilical hernia defects can range from small (<1 cm) to very large/complex hernias, and treatment options should be tailored to the clinical situation. Open, laparoscopic, and robotic options exist for repair, with each having its advantages and disadvantages. In general, mesh should be used for repair, because it has been shown to decrease recurrence rates, even in small hernias. Although outcomes are generally favorable after umbilical hernia repairs, some patients have chronic complaints that are mostly related to recurrences.
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49
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Kaufmann R, Halm JA, Eker HH, Klitsie PJ, Nieuwenhuizen J, van Geldere D, Simons MP, van der Harst E, van 't Riet M, van der Holt B, Kleinrensink GJ, Jeekel J, Lange JF. Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial. Lancet 2018; 391:860-869. [PMID: 29459021 DOI: 10.1016/s0140-6736(18)30298-8] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 11/19/2017] [Accepted: 11/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1-4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias. METHODS We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1-4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1-2 cm and >2-4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24-30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230. FINDINGS Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5-33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4-9·4] vs 11·4% (6·8-18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12-0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths. INTERPRETATION This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1-4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size. FUNDING Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.
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Affiliation(s)
- Ruth Kaufmann
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Surgery, Albert Schweitzer Hospital, Dordrecht, Netherlands.
| | - Jens A Halm
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Hasan H Eker
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Surgery, VU University Medical Center, Amsterdam, Netherlands
| | - Pieter J Klitsie
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Orthopaedic Surgery, HagaZiekenhuis, The Hague, Netherlands
| | - Jeroen Nieuwenhuizen
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Surgery, LUMC, Leiden, Netherlands
| | | | | | | | | | - Bronno van der Holt
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Gert Jan Kleinrensink
- Department of Neuroscience, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johannes Jeekel
- Department of Neuroscience, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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50
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Importance of mesh overlap on hernia recurrence after open umbilical hernia repair with bilayer prosthesis. Am J Surg 2018; 216:919-922. [PMID: 29429547 DOI: 10.1016/j.amjsurg.2018.01.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/07/2018] [Accepted: 01/13/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND importance of mesh overlap on recurrence after open umbilical hernia repair has been poorly studied. METHODS a retrospective cohort study was performed with patients who underwent open umbilical hernia repair with bilayer prosthesis between 2004 and 2015. RESULTS 1538 patients were included. Fifty patients (3.3%) had a mesh overlap lower than 1 cm. After a mean follow-up of 4.1 years 53 patients (3.5%) developed a recurrence. Recurrence was associated with a mesh overlap smaller than 1 cm (10.2% vs. 3.3%, p = 0.010, OR = 3.3). In the logistic regression model an overlap smaller than 1 cm was not statistically associated with recurrence (OR = 2.5, p = 0.123). Female gender, postoperative complications and prosthesis size were associated with hernia recurrence. CONCLUSIONS mesh overlap seems to be an important factor for hernia recurrence. A mesh overlap of at least 1 cm should be used until more studies are performed about this issue.
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